For children and adolescents who have anxiety, going to school can feel like a nightmare. Anxiety is the most common mental health disorder in the United States for adults. And since the COVID-19 pandemic, anxiety that interferes with daily life has risen in young people, making everyday activities like going to school and socializing difficult and more stressful.

In Massachusetts, the upward trend in anxiety-related disorders has led to more students missing school, sometimes labeled chronic absenteeism or school refusal. This leaves parents, families, and caregivers scrambling for solutions, like educational accommodations and mental health counseling—all of which are limited, with long waiting lists to even get in front of a health care provider.

“The mechanisms underlying anxiety—like intolerance of uncertainty, changes, and distress—all went up during 2020, and they haven’t come back down to pre-COVID levels,” says Alyssa Farley, a BU College of Arts & Sciences research assistant professor of psychological and brain sciences. “This raises the question about whether children have really recovered from the experiences of those years.”

Farley is a clinician and supervisor at BU’s Center for Anxiety & Related Disorders (CARD) Child & Adolescent program, where she and her colleagues treat children ages 3 to 17 for various clinical anxiety disorders, such as separation anxiety, phobias, and selective mutism, which is when a child will not speak in certain settings—commonly school—but will speak comfortably in other environments. The clinic also offers guidance for caregivers to help kids succeed.

“I think a lot of the things that we recommend can feel counterintuitive to parents,” Farley says. “For example, instead of accommodating avoidance or enabling children to escape a situation that’s causing them anxiety, we say to gradually work with them to face their fears.”

Farley wishes there was better understanding of anxiety both at home and in schools, since it can be overlooked until a child starts missing school.

The Brink sat down with Farley to discuss why anxiety in children is interfering with school, why it’s so difficult for parents and kids to access resources, and how to support an anxious child.

Based on your work at CARD, how do you make sense of the heightened levels of anxiety among kids and rising school absenteeism?

There are a lot of different factors that contribute to that. There was the period of the COVID pandemic, 2020 to 2021, where kids weren’t in school, and they weren’t facing things that might be challenging for them under normal circumstances. So, for example, a child predisposed to social anxiety could have spent critical developmental years without having any playdates and not going to school in person.

Now school is back to normal, but some kids missed out on key opportunities to practice facing social challenges. For kids that were in their preschool years during the COVID lockdown, they would have started practicing talking with teachers and other kids, and they have really struggled due to missing out on that time.

Another element is screen time. I hear a lot of parents saying their child is completely addicted to their phone or tablet, and that it’s really hard to get them to do other things. For that same period during COVID, daylong screen use became normalized. I think that might be another contributor to school absenteeism now. If school is a factor that causes a child to feel extreme and impairing levels of anxiety, then of course they want to avoid it and stay home instead.

Screen time is just another pull to avoid anxiety—it can be very hard to put aside and go to school instead. A lot of times when we’re trying to get families to help their children attend school more regularly, we have to ask them to remove that reinforcement at home.

How is missing school addressed in the clinic, and what are the options families have?

A lot of times, we work with families to remove the enabling patterns that contribute to school refusal and build skills to help the child attend school more consistently. For example, an anxious child might say they have a stomachache every week and start staying home a lot. Over time, we might realize that anxiety is making them feel physically unwell, or there is something making them really nervous about school that they’re trying very hard to avoid. The source of this anxiety should be addressed, and the family should help the child make it to school as consistently as possible.

We’re always trying to prevent school refusal from becoming a more persistent pattern, because the longer you’re not doing something, the harder it is to jump back into it. When we see children with persistent school refusal, we’re often recommending more intensive treatment than standard outpatient therapy, since that typically won’t be sufficient for a child who has long-term, chronic school refusal.

There have been reports of parents struggling to get accommodations and support for their children who are refusing to go to school because of impairing anxiety. Why do you think that is the case?

It’s typically thought about in terms of internalizing versus externalizing. Externalizing disorders cause behaviors that are disruptive to the class and interfere with the teacher’s flow of the day. Internalizing disorders like anxiety and mood disorders cause inward distress, and are less likely to affect the classroom.

For example, we treat kids who are highly perfectionistic and afraid of making mistakes. They’re at school every day, handing in perfect assignments, which can be positively perceived by teachers and school staff. But, that can actually be driven by a significant underlying anxiety, one that doesn’t call out for a need for help.

As another example, a student with social anxiety or selective mutism might struggle to participate or speak in class. While those are signs of impairment, they can still be easy to overlook because they are not disruptive in nature.

Is there a fear that those students could fall through the cracks, because it’s not behavior that is disrupting the classroom?

Absolutely. With school refusal, it’s common to see that schools will start intervening and making plans when it gets to the point that there is concern about educational neglect. Then measures and steps that need to be taken can seem quite punitive to families. I have worked with kids who have gone to court because they’ve missed too many days of school. But that’s not addressing the underlying problem.

How would you like to see schools improve the way students are supported?

I would wish for greater awareness of what anxiety looks like and the ways that it can interfere. Anxiety can actually be really impairing and prevent a child from reaching their potential in a range of ways. I’d like to see more training on how to identify signs of anxiety for both families and school staff. There’s a lot of misidentification and misunderstanding of anxiety disorders that–until a child is not showing up for school–can cause them to be overlooked.

Teachers are often well-positioned to identify a mental health concern. To address this, we have made efforts to support them, such as through the development of online trainings designed in our team’s collaboration with Jennifer Greif Green, a professor in special education and a child clinical psychologist at BU’s Wheelock College of Education & Human Development. The training helps with identifying the different signs that a child might be struggling with their mental health and how to check in with the child in an effective and supportive way—and also how to refer them to school- or community-based mental health services if needed.

Is there similar training for parents and caregivers who have a child struggling with anxiety?

That’s something I would like to develop. At the clinic, we provide parents with education around ways they interact with their child, so that they can be more effective in helping their child overcome anxiety. And it’s oftentimes not intuitive. Maybe they’re providing their child with a lot of reassurance all the time, or they’re jumping in whenever they see their child starting to feel a little bit anxious, or they’re saving them from hard situations or allowing them to avoid them. We call those the “parent traps,” since that is what parents often naturally do when they have the very best intentions. It’s in the effort to protect your child and can be helpful in the short run, but it can maintain and exacerbate anxiety in the long run.

If you were to give general tips for parents and caregivers, what would they be?

Acknowledge your child’s feelings and express confidence in their ability to do hard things. There can be a tendency to minimize anxiety by saying things like, “Oh it’s going to be so easy, nothing to worry about, relax it’s fine”—but that language doesn’t really help. We encourage parents to label their child’s feelings, empathize with their emotions, and provide encouragement. You might say, “I can tell that you’re feeling really scared and I get it. I know that this is really hard. But you’ve got this. You can do it.”

I would also say, help your child to challenge their own anxious thoughts. Support your child in gradually facing their fears. Notice and praise instances of bravery, and practice modeling bravery—kids pick up on all their parents’ cues.